In Our Prime

by Patricia Cohen

  To Wilson, class differences were what made estrogen socially meaningful. He implied that regular hormone treatments kept one’s social status intact, and personally recommended Estradiol, which he called the “Cadillac of hormones.” His animosity is reminiscent of the British prime minister in C. P. Snow’s dystopian novel New Lives for Old, who urges doctors to keep their discovery to elites, “those of the highest gifts, of the finest aims.”

  In 1975, doctors wrote 27 million prescriptions for hormone replacements, which generally consisted of estrogen-only pills given in a variety of high dosages. Then, in December of that year, the New England Journal of Medicine published a series of articles that reported women who used estrogen for five years were five times more likely to develop endometrial cancer; those on the hormone for seven years were fourteen times as likely. A few weeks later, the Food and Drug Administration issued a warning about prolonged use, particularly in women without debilitating menopausal side effects.

  As the women’s movement rippled out from radical feminists to thousands of small discussion and consciousness-raising groups organized by suburbanites and professionals, women encouraged one another to reclaim responsibility for their health from the medical profession. The Boston Women Health Care Collective published Our Bodies, Ourselves, which became a female health bible. Here the empowering aspect of self-help was effectively employed to challenge the patronizing and paternalistic attitudes of mostly male physicians. Wilson’s idea of questioning your doctor was one they supported, though not for the reasons he listed. Feminists were critical of the hormone push; they argued the body would naturally reach a new hormonal balance as it aged. Different medical specialties reacted differently to these ideas. By the end of the 1970s, for example, standard psychological texts had discounted menopause as a direct cause of depression or crisis, and prescriptions for estrogen dropped to 14 million as evidence mounted that it led to a higher risk of uterine and breast cancer.

  In the 1980s, estrogen-only formulas were replaced by a combination of estrogen and progestin, and many gynecologists recommended their use for postmenopausal women, hoping additional benefits, such as preventing heart disease, memory loss, and the bone-weakening effects of osteoporosis, would surface. (Few did.) The platoons of female baby boomers, more outspoken about menopause and more committed to retaining their youth, constituted a large pool of consumers. “More than 30 million women in the baby boom generation . . . will pass age 40 over the next two decades,” the Los Angeles Times noted in a story on the “meno boom” in 1989. Whispers about menopause were replaced by public discussion. Gail Sheehy, Gloria Steinem, and Germaine Greer published books on the subject in 1992 and 1993. The following year, a workshop sponsored by the National Institutes of Health concluded that menopause has unfortunately been associated with illness and was often “treated” as a medical problem rather than as a normal part of a woman’s life. For most women, menopause was not a watershed event but more like hair growth, something that happened gradually over a period of years. Hormone therapy was what the medical sociologist John McKinlay called “a treatment in search of a disease.” Conflicts over dosages, treatment length, and benefits continued, but through the close of the century, hormones remained a huge business, if not for the supposed miseries of menopause, then as an antiaging treatment—just as Sherman Kaufman had suggested in Ladies’ Home Journal in 1965. MIDUS I researchers found that women most frequently cited concern over a youthful appearance as the reason for taking the pills.

  Attitudes abruptly veered in 2002. The National Institutes of Health unexpectedly halted the Women’s Health Initiative’s clinical trials of a hormone therapy that combined estrogen and progestin because of the stunning news that the treatments increased the risk of breast cancer, heart disease, blood clots, and stroke. Sales of hormones plunged.

  Many doctors and antiaging practitioners still recommend hormone therapy in lower doses, and public confusion about the benefits and drawbacks persists. In April 2011, the Women’s Health Initiative created a new muddle when it announced that women from the study who had hysterectomies and had taken an estrogen-only pill were significantly less likely to suffer from breast cancer and heart attacks. (About one-third of American women in their fifties have had their uteruses removed.) Experts reacted to the news with wariness, especially because the older women in the study had taken a prescription, Premarin, which is not used much anymore. The health initiative repeated that its recommendations were unchanged: a woman with a uterus should take a low-dose combination of estrogen and progestin only if she had severe symptoms and for as short a period as possible.

  The expert reversals and qualifications can have the unfortunate effect of undermining confidence in scientific findings, as people come to expect that today’s cutting-edge pronouncement will be contradicted by tomorrow’s. Perhaps more usefully, the tangle of information should instill caution about astonishing medical claims, reminding us of how little we know about the human body’s mysteries.

  The Business of Sex

  The gradual decline in regular, heart-pounding sex is a familiar midlife regret. Fifteen, twenty, or thirty years into a marriage or relationship, it is not surprising that sex can become, as the novelist William Kennedy put it, like “striking out the pitcher,” satisfying though predictable. The impression fostered by the current lineup of wet-lipped women and randy men on display in print and on-screen, however, is that ubiquitous desire is common and normal. Twenty-something or 60-something, these knowledgeably carnal adults eagerly hop into bed whenever possible, enjoying multiple partners and orgasms. In the popular culture, female independence is often signaled by sexual aggression rather than accomplishments, financial security, or intelligence. Openness about sex is certainly preferable to the Victorian era’s embarrassed silence, yet today’s overexposure to standardized portrayals of Stepford sex asserts its own form of tyranny, raising expectations and anxieties about sexual performance and appetite at all ages, especially the middle decades. What’s wrong with me? Why am I missing out on all the fun?

  In 1998, when the Food and Drug Administration for the first time approved a treatment for male impotence, Viagra, doctors developed hand cramps from responding to requests for prescriptions. The market for male libido lifters reached $2 billion in 2010. Drug companies reportedly spend $100 million each year on advertising treatments for male impotence or flagging desire, rebranded as erectile dysfunction (or preferably by its nonrevealing initials, ED).

  After the phenomenal financial success of Viagra, the feverish hunt for a female counterpart was on. Within a year of the drug’s approval, scientific and professional conferences sprang up in the United States and abroad about female sexual dysfunction (FSD), an abnormal absence of desire frequently mentioned in connection with middle-aged women, both pre-and postmenopausal.

  The effort to find a pharmacological answer to FSD was further energized by a 1999 article in the Journal of the American Medical Association about a study which estimated that forty-three percent of women between the ages of 18 and 59 suffered from sexual dysfunction. Drug companies and women’s groups seized on the results to protest that female sexual problems deserved as much attention as male ones.

  This examination of the sex lives of 1,749 women and 1,410 men had serious flaws. Anyone who reported problems with sexual desire, arousal, orgasm, pain, pleasure, or minor anxiety about sexual performance over a period of two months was included in the sexual dysfunction category. Such troubles were often reported by women who were dissatisfied with their partners or single, had physical or mental health difficulties, or had experienced a recent social or economic setback. Any woman who might have mentioned a disappointing sex life because she had just lost a job, developed a painful backache, was contemplating a divorce, or suffering from depression was labeled as having a sexual disorder. Two of the study’s authors had links to Pfizer, which was in the process of developing a drug for FSD.

  A series of scientists
challenged this research, arguing that female sexual dysfunction was essentially a newly concocted syndrome fabricated by the drug industry. Writing in the British Medical Journal in 2003, Ray Moynihan called female sexual dysfunction “the freshest, clearest example we have” of a disease created by pharmaceutical companies. “A cohort of researchers with close ties to drug companies are working with colleagues in the pharmaceutical industry to develop and define a new category of human illness at meetings heavily sponsored by companies racing to develop new drugs.”

  More recent surveys have estimated that seven to fifteen percent of women between 20 and 60 are distressed about problems related to drive, arousal, and orgasm, significantly fewer than the forty-three percent trumpeted by the 1999 study. Even these figures may exaggerate the problem. All the studies that found more than one in ten women were affected were financed by drug companies. In truth, research on female sexuality is sparse and ambiguous. It is not at all clear how many of these problems are signs of a sexual disorder and how many are related to other physiological dysfunctions or social pressure. Nor do scientists know how many middle-aged women might be affected.

  Viagra and its competitors essentially work on a mechanical problem. The drug increases blood flow to the penis to produce an erection. The effect of a treatment can be measured. That isn’t the case with female sexuality, a combination of desire, arousal, and gratification that cannot be gauged with a ruler. As a Harvard Medical School newsletter put it: “Without an empirical standard by which to assess female sexual function, it would seem difficult, if not impossible, to come up with criteria for female sexual dysfunction.”

  Judgments about what a disease or disorder is reflect social and historical currents as much as they do science. Moral pronouncements have always had a hand in demarcating the border between sickness and health. In 1898, James Foster Scott warned men over 50 that sexual overexertion was bad for their health. Until it was removed in 1987, homosexuality was classified as a disorder in the Diagnostic and Statistical Manual of Mental Disorders, or DSM, the handbook published by the American Psychiatric Association. Changing norms and the development of the gay rights movement put muscle behind empirical evidence to bring about the reclassification. The level of female desire that certain doctors, advocates, and television writers consider normal would have been labeled nymphomania in previous eras. In the eighteenth and nineteenth centuries, lascivious glances from a woman were considered a sign of sexual madness, possibly brought on by masturbating, spinal lesions, an enlarged clitoris, reading novels, or eating too much chocolate.

  Female sexual dysfunction was added to the manual in 1980 and is essentially defined as “persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity.” No clear diagnostic keys distinguish someone who has it from someone who doesn’t, and the process of updating the manual for the fifth edition, scheduled to appear in 2012 or 2013, has sparked vigorous arguments over how to improve the diagnosis.

  The distress that plagues many people about their sex lives may be as much of a cultural phenomenon as a physiological one. Media portrayals of consuming, aching desire in the middle years have become common. Leonore Tiefer, a clinical associate professor of psychiatry at New York University Langone Medical Center, criticizes what she sees as “the mandatory participation in high frequency, high pleasure, high desire culture,” or the pressure to have “sex—womb to tomb.” Some plastic surgeons have said that widespread images available on-screen, on the Internet, and in magazines have inflamed concerns about the aesthetics of female sexual organs. They have been visited by women who say they have become self-conscious about the appearance of their genital features. Though there are no verifiable statistics on the emergence of genital plastic surgery, some doctors have reported that women are coming in for “vaginal rejuvenation.” “I was very, very self-conscious about the way I looked,” one middle-aged patient explained. “Now I feel free. I just feel normal.” In 2010, the first global symposium on a “new subspecialty,” genital cosmetic surgery, was held in Orlando, Florida.

  Lori Brotto, a psychologist who is overseeing the DSM’s revised entry on female sexual disorder, is wary that conceptions of normal desire often reflect a male perspective. Persuaded by research from Rosemary Basson, a clinical professor in the Departments of Psychiatry and Obstetrics & Gynecology and one of her collaborators at the Center for Sexual Medicine at the University of British Columbia, Brotto believes that a focus on urges may be misleading. For women, desire is triggered by arousal. A decision to have sex, to be responsive to a partner’s touch, may be at the core of the female sexual response, rather than an inescapable impulse.

  In 2010, researchers who analyzed the latest MIDUS results reported evidence of a gender gap in middle age sex. At age 55, men can expect an average of 15 more years of an active sex life, while women can look forward to 10.6 years. One explanation the researchers offered was that many more men in their late 60s have regular partners than do women of the same age. Another is the increased use of drugs that stoke men’s sexual capacity. Tiefer believes the push for a “female Viagra” follows men’s artificially induced sexuality.

  Pfizer initially undertook testing to prove that Viagra could work for women as well as men, but admitted in 2004 that this was not the case because female sexual disorders were the result of “a broad range of medical and psychological conditions.” Procter & Gamble’s attempt to get the FDA to approve a testosterone skin patch for some women was rejected that same year because of a possible increase in the risk of breast cancer and cardiovascular disease. Other variations are in the works. The Illinois-based BioSante Pharmaceuticals has been developing a testosterone patch, while Acrux, an Australian company, has tested a testosterone-based spray for women.

  The German pharmaceutical company Boehringer Ingelheim announced in November 2009 that it had completed the pivotal Phase III clinical trials of the drug flibanserin, used to treat the most common form of FSD, hypoactive sexual desire disorder (HSDD). The company reported that North American women in the trial had an average of 4.5 “sexually satisfying events” a month, compared with 3.7 by women who took a placebo and 2.7 by those who did not take any pills. Interestingly, European women did not register any significant change, an indication of how “cultural fictions” play an important role in expectations about sex.

  Flibanserin was meant to treat depression but was ineffective. That meant it was a drug in search of a disease. The process brings to mind Latisse, the eyelash lengthener released in 2009 by Allergan, the maker of Botox and Juvéderm. Initially developed to treat glaucoma, Latisse turned out to have a much more profitable side effect: longer lashes. Before it could be sold as a prescription drug, however, Allergan needed the Food and Drug Administration’s stamp of approval. But the FDA found itself in a quandary: What disease or condition was this new drug purporting to treat? None existed, so the FDA created one: hypotrichosis of the eyelashes, or not having enough hair. (The company is currently investigating how to treat hypotrichosis of the scalp—also known as baldness.)

  Finding a disease to fit the cure is similar to what advertising copywriters did in the 1920s, when they invented hundreds of syndromes, like bromhidrosis (sweaty foot odor) and acidosis (sour stomach). It is what the cosmetics and dermatology industries are currently trying to do to wrinkles—to get consumers to see them as a form of dermatosis, a skin disease. The American Society of Plastic and Reconstructive Surgeons employed the strategy in 1983 when it used the term “micromastia” for small breasts. A memo sent by the society to the FDA declared that “a substantial and enlarging body of medical information and opinion” believes “these deformities”—small breasts—“are really a disease,” since they create “a total lack of well-being.” Plastic surgeons assured patients that “normal breasts” could be achieved through augmentation surgery.

  As the 2010 date approached for the Food and Drug Administration’s ruling on flibanserin, Boehringer
Ingelheim launched a publicity campaign that included a website, Twitter feeds, and a documentary about the supposedly widespread problem of HSDD, declaring that six out of ten premenopausal women suffer from it—a claim disputed by a number of independent researchers. As part of a medical education class sponsored by the German pharmaceutical, doctors and nurses were asked to diagnose a 42-year-old working mother who cares for three children and her sick mother, and has no desire for sex. The correct response, the company instructed, was to evaluate her for a sexual-desire disorder.

  “This is really a classic case of disease branding,” said Dr. Adriane Fugh-Berman of Georgetown University’s medical school, who frequently testifies on behalf of plaintiffs in lawsuits against pharmaceutical companies. “The messages are aimed at medicalizing normal conditions, and also preying on the insecurity of both the clinician and the patient.”

  Michael Sand, director of clinical research at Boehringer Ingelheim, conceded the company has no idea how flibanserin works. “We don’t understand the pathways,” he said. “What we think is that in women with HSDD there is likely an imbalance of serotonin, and that flibanserin is balancing the imbalance in these neurotransmitters.” With flibanserin, the company has shifted the focus from hormones to psychology. Boehringer Ingelheim is guessing that brain chemistry is at the root of the problem. A Kinsey Institute survey found that general well-being was the most frequently cited contributor to female sexual satisfaction, followed by emotional reactions, attractiveness, physical responses to lovemaking, frequency of sexual activity with a partner, the partner’s sensitivity, one’s own state of health, and a partner’s state of health. This is not to say that middle-aged women and others do not suffer from sexual problems, only that a pill may not be the cure-all. Mindfulness training and cognitive therapy have also had success in raising low sexual desire.